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Table 4 Used TCM components of included studies

From: Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review

Study ID

 

Clemson 2016 [28]

López Cabezas 2006 [29]

Rich 1995 [30]

TCM Component

Definition

Pre hospital discharge

Post hospital discharge

Pre

hospital discharge

Post

hospital discharge

Pre hospital discharge

Post hospital discharge

1

Screeninga

Targets the key evidence-based risk factors from those who would benefit from the TCM intervention. According to Hirschman [31] the risk factors for eligible patients are: ≥ 5 active chronic conditions, a recent fall, deficits in basic activities of daily living (ADL), a diagnosis of dementia or poor performance on cognitive impairment screening tools, history of mental or emotional health problems and hospitalization within the past 30 days or ≥ 2 hospitalizations within the past six months.

X

a

X

a

X

a

2

Staffinga

Consists of the delivery and coordination of care is executed by the same master’s prepared advanced practice registered nurse (APRN), who assumes primary responsibility for the care of patients.

Xb

a

Xb

a

Xb

a

3

Maintaining Relationships

Key feature of TCM to maintain and promote respectful and trusting relationships with patients and their family caregivers. This includes not only home visits and telephone calls, but also availability of the APRN or the health professional in charge of the intervention seven days a week.

X

X

X

X

X

X

4

Engaging Patients and Caregivers

Consists of the development and application of a discharge education and care plan in collaboration with the medical team, the patient and the caregivers. This plan includes the patient goals and preferences, among others.

X

   

X

 

5

Assessing/Managing Risks and Symptoms

Comprehensive and targeted assessment to determine changes in the patient health status as well as a complete management of symptoms to prevent their onset or their risks.

X

X

X

X

X

X

6

Education/Promoting Self-Management

Involves the implementation of educational and behavioral strategies to meet the patients and caregivers learning needs related to an adequate and immediate response to the worsening of symptoms.

  

X

X

X

X

7

Collaborating

Refers to the furthering of consensus on the patients’ plan of care between patients and members of the healthcare team.

    

X

X

8

Promoting Continuity

Highlights the follow up of the patients by the same medical care team, in order to avoid interruption of the patients’ plan of care.

X

X

X

X

X

X

9

Fostering Coordination

Encourages the active communication between healthcare team and community-based practitioners, where the APRN in collaboration with patients, caregivers and team care members may identify the need for additional services.

    

X

X

Total:

6/9

3/7

6/9

4/7

9/9

6/7

  1. aSince it is the same sample and the same staff as in the pre-discharge phase, these components are not needed to be used again after the hospital discharge. bThe intervention was carried out by other health professionals, such as occupational therapists [28], Pharmacists [29], and multidisciplinary team - including nurses among others health professionals [30]